Midwifery is catching

What an exciting day for maternity care in Australia! We stand on the threshold of change and the possibilities are endless.

Hang on - haven’t we been here before? Why do I get a sense of de ja vu? Well, we have had a large number of these in the past with no change whatsoever, so I’m not holding my breath.

Details and ways to make submisions are here on the Department of Health and Ageing’s website. Submissions close end of October, with the review to be released next year.

What I’m worried about is that it will become a turf war between doctors and midwives, between doctors and hospitals and midwives, between women and insurers and generally everyone who has something to say about it. We don’t need a turf war - that’s already been had, and the women lost (I’ll leave debates as to who won up to other people, because I don’t actually care beyond that one statement).

There is a need for reform because women only get choice and continuity of care and carer when they pay for it out of pocket, and even then it’s sometimes a figment of someone else’s imagination that continuity is what they get… but when women will settle for their ob being there for 15 minutes for the arrival bit of their birth, or the 1/2 hour it takes to do a c-section, thinking that that’s good service because they know who he is, then there is something screwy with the system. Same with settling for having a complete stranger of a midwife because yours has "timed out" for that day or week.

The focus needs to be on what women want and need. This is a spectrum of things, from "unassisted birth with an easy path to registering their child" through midwife-attended or -assisted homebirths, into small hospitals, through to tertiary hospitals and then out  the other side into private hospitals and private obstetricians. To name just a few of the options.

I’d like to see something like New Zealand has, where the money follows the woman around. This could mean that obstetricians earn less and midwives earn more. It could mean that homebirth numbers rise because it is a SAFE option for birth, and possibly the safest but not the most socially acceptable still (I’m working on that). It should mean that more women have the chance to get to know their caregivers, and have them attend their birth, if that’s what they want. Lots of women don’t know anything different from the fragmented care system that exists and is delivered to the masses. Education as to their options, beyond this, need to be supported by the money.

Women can want all they like in the direction of a private midwife and a homebirth, but when their private obstetrician and a 6 day stay in hospital is "free" under private health insurance and Medicare, and a private midwife and homebirth is $3000+, and a public hospital birth is free, it can be a hard decision to make. Families make the decision to homebirth regardless of the cost only when they see the benefits and for a lot of people, there aren’t any because they can’t see them (fish, water, same analogy…). Same with birthing with an epidural or not - some would say they’d never go to a dentist without anaesthetic and others would say it’s a huge interference in the natural order of things.

Way off track from saying - go forth and read and respond, for tomorrow or next year or next decade, it may be you or someone you love or someone you know who’s making these choices.

I get asked by women I am following through a pregnancy - should I make a birth plan? What kind of birth plan? Long or short? How? What to put in it? So some dot points from experience:

• If you want a birth plan, then consider a homebirth because otherwise you are having to negotiate on someone else’s playing field. You don’t know where the towels are = you aren’t in control
• Make it short and sweet. One page. Dot points. No ifs, buts or maybes. If it is important enough to write down, it’s important enough to state plainly.
• Don’t put "unless medically indicated" because this is a great out for anyone. If you don’t give them that out, you will have to be negotiated with.  

Areas that you will want to consider:

• Support people
• Vaginal examinations
• IV canula - say no to these routinely, and if it needs to be inserted, tell them where they can stick it
• Wearing your own clothes (singlet and sarong, undies, pink wig, scarf and thongs, whatever…)
• Catheterisation
• Monitoring
• Pain relief (do not offer me pain relief, or offer me massage, heat packs, pressure points, reiki, reflexology, aromatherapy, shower, water etc only)
• Food and drink (because you are after all an adult and can work these things out for yourself!)
• First stage - say plainly that the bed needs to be moved, or room made for ball, beanbag or whatever. Do not ask for permission but make a statement.
• Second stage - declare that you will not need guided pushing, that either you or your partner will catch the baby, that you want a lotus birth, that the first words your child will here will be a prayer to the goddess or the Sun, or whatever you want.
• Third stage - how do you want your placenta dealt with? Do you want to keep it, or make prints,
• Fourth stage - BONDING!! So important! You will have to be clear about bathing, weighing, immunisation, and vitamin K (these last two will be asked of you a couple of times during labour which is really irritating!), feeding, rooming in. 
• Afterwards - if you plan on being in hospital for a few days, think about heel prick tests, bathing, circumcision, immunisation etc.

You will have to do research into these things, and I encourage you to do so before giving birth. It is going to be hard to get your hands on information about these things with a newborn and away from your usual resources (read: the internet and your own phone).

And people ask me - do I need a c-section plan? I’m of two minds about this, because if you plan for it are you headed for it, and yet on the other hand our c-section rate here in Australia is more than 1 in 3, so chances are relatively high if you birth in a hospital and higher in some than others. Investigate this before birthing somewhere. And in the end yes, I do suggest you write a plan because it’s in a c-section situation that you will want to have what aspects of the birth you are wanting especially respected. Again, look at skin to skin contact, immediate baby care, partners staying with your baby if they need to be taken somewhere.

Look on the interwebs to find some examples and think about it before talking to your care provider or a friendly midwife. 

Photos of the recent Independant Midwives Association of South Australia meeting when I gate crashed and presented stuff about kangaroo care to with some fellow students! There were some semi-famous people there and other students from the university here.

Oh dear here we go to name them all - front row (L-R): lovely student who works at close to city but in the country hospital, JF, me!!!, Megan, Ms Reflexologist 

Back row: Lisa Barrett, Rose, Ros, another IM, Rosie, Tania, student, student, Kate, Kylie

More photos:

A long long time ago, I wrote a post about how much a homebirth cost. It is my most popular post by far and I am feeling the need to update it.

*EDITED* to add that these costs are not for private births per se - the ones Anna gave me are for New Zealand and not for Australia.

The costs that I quoted were from enquiries in Sydney, so let me upate for Adelaide. Rumour has it (as in, I’ve never felt the need to ask midwives directly but people who have had homebirths have hinted around these numbers) that a privately attended birth here will cost $2,000 - $3,000 rougly: a little less here, a little more there, up to $4,000 one person reported to me (but that included a few extras). The hire of a birth pool is usually extra to this. 

A few of the comments have questioned the $50k figure I put on business costs. I wasn’t clear there but I will say that those costs would be that high to cover the cost of self-insurance if that’s the way that I wanted to go.

Anna gave me me some New Zealand figures to work with:

4 births a month @ $2,000 each roughly, from the NZ government = $8,000
$900 in business costs a month = $7,100 / year
If I assume one month off a year, that’d be $78,100 a year

Homebirths cost $400 more to the midwife because of the calling in of a second midwife so potentially up to $17,600 less, so $60,500 (but perhaps this is balanced out by being the "second midwife" occassionally?)

So there you go, an update and a reflection of how it might be in Australia if we ever had a homebirth policy! 

Please go and read about this and see what you think.

Add to this - if you want a physiological third stage in a hospital setting, the words "lotus birth" will guarantee that no one severs the cord. Even if you have no intention of keeping the placenta until the cord falls off on its own, it will keep people from cutting cord, which is one of the only ways to insist on letting the baby get its full compliment of blood.